Resection of over 290 polyps during emergency surgery for four intussusceptions with Peutz-Jeghers syndrome: Report of a case

A 41-year-old male patient with aggravated epigastralgia and nausea was admitted to Central Aizu General Hospital in February 1997. His past history showed a colonic polyp and anemia in the fourth decade. The patient looked healthy, but showed abdominal distension and tenderness, and pigmented lips. A plain abdominal X-ray revealed a dilation of the small intestine with niveau. Computed tomography disclosed multiple target signs. An emergency laparotomy clarified four intussusceptions of the small intestine with numerous polyps. Three were successfully reduced, while one jejunal intussusception was resected. Due to a fear of recurrence, a total of over 290 polyps were removed. His illness was diagnosed to be Peutz-Jeghers syndrome with a histology of hamartomatous polyps. He thereafter did well for 6 years, when he underwent an ileal resection for another intussusception caused by a newly grown lipoma. He was able to retain his job, but anemia and hypoproteinemia due to the proliferation of polyps necessitated treatments at the outpatient clinic. In May 2005, he underwent a third emergency laparotomy for an intussusception, followed by a resection of the ileum and 54 polyps. Since then he has been able to lead a normal life.

[The Peutz-Jeghers syndrome--a case review]

INTRODUCTION

The authors present a case review of a localized Peutz-Jeghers syndrome of the caecum, emulating a carcinoma.

METHODS

The patient who presented with insignificant family history with a diagnosed stenosing tumor of his appendix and histological findings of highly suspected adenocarcinoma, was indicated for surgical revision and right-sided hemicolectomy.

RESULTS

The patient underwent laparoscopically assissted right-sided hemicolectomy and his postoperative course was adequate. The final histological finding diagnosed solitary hamartoma of the Peutz-Jeghers polyp.

CONCLUSION

Differential diagnostic reasoning in patients with negative family history and unclear case history with findings of polypous tumorous lesions of the GIT, should also consider the Peutz-Jeghers syndrome. The syndrome is related to a high risk of malignancies in the elderly.

STK11/LKB1 germline mutations in the first Peutz-Jeghers syndrome patients identified in Slovakia

Peutz-Jeghers syndrome (PJS) is characterized by number of hamartomatous polyps in the gastrointestinal tract and by mucocutaneous hypermelanocytic lesions at different sites. Older patients have an increased risk of the cancers of small intestine, stomach, pancreas, colon, esophagus, ovary, testis, uterus, breast and lung. In majority of PJS cases, the germline mutations in serine/threonine kinase STK11/LKB1 gene were found to be associated with disease. Here we report the results of a first mutational screen of STK11/LKB1 in PJS patients characterized in Slovak population. The first patient with unusual carcinoma of duodenum was a sporadic case and carried c.842delC change residing in a mutational C6 repeat hotspot. Neither the polyp nor the tumor of the patient displayed the loss of heterozygosity at the site of mutation suggesting different mechanism involved in the formation of polyp and tumor in this case. The second patient belonged to a three-generation family with typical PJS features but not cancers. Interestingly, the patient displayed concomitant occurrence of adenomatous and hamartomatous polyps. Molecular analysis revealed an IVS2+1A>G mutation that alters the second intron 5' splice site and was shown to lead to aberrant splicing mediated by the U12-dependent spliceosome. The same mutation was present in the 9 affected members of the family but in none of their normal relatives. We also observed novel c. IVS2+61G>A unclassified variant, and recurrent IVS2+24G>T and 3UTR+129C>T polymorphisms. Based on the achieved results, we could offer predictive genetic testing and counseling to other members of the patient's families.

[Polyposis of the stomach. Endoscopic treatment or follow-up?]

Out of 3243 patients with gastric polips, polyposis was diagnosed in 298 ones including 135 cases of complicated and 163 cases of uncomplicated forms. Hyperplastic polips were diagnosed in 281 patients. Along with hyperplastic polyps, solitary adenomas were diagnosed in 9 cases, Peitz-Jegerc polyps - in 6, and juvenile polyps - in 2. Polypectomy was performed in 153 patients: partial - in 104, and total - in 49. Follow-up was carried out in 98 non-operated patients, indications for endoscopic surgery were seen in 18 cases. After partial endoscopic polypectomy, repolypectomy was performed in 24 cases: single - in 8, multiple - in 16. Repeated endoscopic treatment after total polypectomy was performed in 3 patients. There were no cases of polyp transformation into cancer. Open surgical treatment was not performed. There were no severe complications after endoscopic treatment.

[Hereditary digestive hamartomatous polyposis syndromes]

Several hereditary syndromes with multiple digestive hamartomatous polyps are described; they are produced by germline mutations. All of them are associated to an increased risk of colorectal cancer and other neoplasms, by the suppressor class of the mutated gens probably. The Peutz-Jeghers syndrome, the Juvenile plyposys syndrome, the PTEN hamartomatous tumor syndrome, and other less frequent hamartomatous syndroms are described.

Genetic testing for colon cancer

Colon cancer remains the third leading cause of death due to cancer in the US, where it affected more than 145,000 individuals in 2005. Up to 30% of these cases exhibit familial clustering, which means that tens of thousands of individuals have a disease with a potentially definable genetic component. Approximately 3-5% of colon cancers are associated with high-risk, inherited colon cancer syndromes. Identification of the genes that cause these colon cancer syndromes, coupled with additional insights into their clinical course, has led to the development of specific management guidelines--and genetic tests--that can diagnose these familial disorders. These guidelines can be life-saving, not only for the affected patient, but also for their family members.

Peroperative enteroscopy and polypectomy in Peutz-Jegher syndrome

We report a 32-year-old who lady when presented with anemia and was detected to have Peutz-Jegher syndrome. She had malignancies of the colon and ovary over a 2-year follow up and was successfully managed. On screening the family two more members were confirmed to have Peutz-Jeghers syndrome and have been put on surveillance.

Laparoscopic-assisted double-balloon enteroscopy for small-bowel polyp surveillance and treatment in patients with Peutz-Jeghers syndrome

BACKGROUND

Surveillance and treatment of small-bowel polyps in patients with Peutz-Jeghers syndrome (PJS) can be challenging and may require intraoperative enteroscopy. While initial reports that used double-balloon enteroscopy (DBE) for the resection of small-bowel polyps in patients with PJS appear promising, complete enteroscopy when using this technique may require multiple procedures or may not be possible at all.

OBJECTIVE

To develop a single-procedure approach to the surveillance and the treatment of small-bowel polyps in patients with PJS.

DESIGN

Retrospective review.

SETTING

Single, North American tertiary-care center.

PATIENTS

Individuals with PJS and small-bowel polyps identified by other modalities.

INTERVENTIONS

DBE was combined with laparoscopy as a single-procedure surveillance and therapeutic strategy for small-bowel PJS polyps.

MAIN OUTCOME MEASUREMENTS

Completion of enteroscopy, number of polyps resected, procedure duration, complications.

RESULTS

Three patients with a history of PJS and known small-bowel polyps underwent laparoscopic-assisted DBE (LADBE). Complete enteroscopy was performed, and all polyps larger than 0.5 cm were resected endoscopically. No cases of cancer or dysplasia were noted; procedure times lasted from 1 to 4 hours. Postoperative complications included ileus in 2 patients.

LIMITATIONS

Small sample size, single-center experience.

CONCLUSIONS

LADBE holds promise as a new technique that can be used as both a surveillance and a therapeutic tool for small-bowel polyps in patients with PJS.

Laugier Hunziker syndrome

Laugier-Hunziker syndrome is characterized by idiopathic mucocutaneous pigmentation that may be associated with longitudinal melanonychia. The significance of this condition is due to its inclusion in differential diagnoses of pigmentary disorders of the oral mucosa, especially Peutz-Jeghers syndrome.

[Rare case of duplex colon invagination]

Authors recite the records of a patient (26) with a 3-year history of dubious abdominal complaints and subileus resulting in numerous examinations and surgical observations, with the diagnosis of lower abdominal pain of unknown origin. He was acutely admitted to the department of surgery because of haemorrhage ex ano and convulsive left abdominal pain. Image creative examinations revealed ileus of a probable invagination origin. Partial resection of the transverse colon with "end to end" anastomosis was performed. Histology verified Peutz-Jeghers syndrome. The authors draw attention to the fact that although invaginations are rare above 18 years, when verified preoperatively, elective procedures can be carried out with lower risk to the patient.

LKB1 exonic and whole gene deletions are a common cause of Peutz-Jeghers syndrome

BACKGROUND

LKB1/STK11 germline mutations cause Peutz-Jeghers syndrome (PJS). The existence of a second PJS locus is controversial, the evidence in its favour being families unlinked to LKB1 and the low frequency of LKB1 mutations found using conventional methods in several studies. Exonic and whole gene deletion or duplication events cannot be detected by routine mutation screening methods.

OBJECTIVE

To seek evidence for LKB1 germline deletions or duplications by screening patients meeting clinical criteria for PJS but without detected mutations on conventional screening.

METHODS

From an original cohort of 76 patients, 48 were found to have a germline mutation by direct sequencing; the remaining 28 were examined using multiplex ligation dependent probe amplification (MLPA) analysis to detect LKB1 copy number changes.

RESULTS

Deletions were found in 11 of the 28 patients (39%)--that is, 14% of all PJS patients (11/76). Five patients had whole gene deletions, two had the promoter and exon 1 deleted, and in one patient exon 8 was deleted. Other deletions events involved: loss of exons 2-10; deletion of the promoter and exons 1-3; and loss of part of the promoter. No duplications were detected. Nine samples with deletions were sequenced at reported single nucleotide polymorphisms to exclude heterozygosity; homozygosity was found in all cases. No MLPA copy number changes were detected in 22 healthy individuals.

CONCLUSIONS

These results lessen the possibility of a second PJS locus, as the detection rate of germline mutations in PJS patients was about 80% (59/76). It is suggested that MLPA, or a suitable alternative, should be used for routine genetic testing of PJS patients in clinical practice.

Exonic STK11 deletions are not a rare cause of Peutz-Jeghers syndrome

BACKGROUND

Peutz-Jeghers syndrome (PJS) is a rare, autosomal dominant cancer predisposition syndrome characterised by oro-facial pigmentation and hamartomatous polyposis of the gastrointestinal tract. A causal germline mutation in STK11 can be identified in 30% to 80% of PJS patients.

METHODS

Here we report the comprehensive mutational analysis of STK11 in 38 PJS probands applying conventional PCR based mutation detection methods and the recently introduced MLPA (multiplex ligation dependent probe amplification) technique developed for the identification of exonic deletions/duplications.

RESULTS

Nineteen of 38 probands (50%) had detectable point mutations or small scale deletions/insertions and six probands (16%) had genomic deletions encompassing one or more STK11 exons.

CONCLUSIONS

These findings demonstrate that exonic STK11 deletions are a common cause of PJS and provide a strong rationale for conducting a primary screen for such mutations in patients.

High proportion of large genomic STK11 deletions in Peutz-Jeghers syndrome

Germline mutations in the STK11 gene have been identified in 10-70% of patients with Peutz-Jeghers syndrome (PJS), an autosomal-dominant hamartomatous polyposis syndrome. A second locus was assumed in a large proportion of PJS patients. To date, STK11 alterations comprise mainly point mutations; only a small number of large deletions have been reported. We performed a mutation analysis for the STK11 gene in 71 patients. Of these, 56 met the clinical criteria for PJS and 12 were presumed to have PJS because of mucocutaneous pigmentation only or bowel problems due to isolated PJS polyps. No clinical information was available for the remaining three patients. By direct sequencing of the coding region of the STK11 gene, we identified point mutations in 37 of 71 patients (52%). We examined the remaining 34 patients by means of the multiplex ligation-dependent probe amplification (MLPA) method, and detected deletions in 17 patients. In four patients the deletion extended over all 10 exons, and in eight patients only the promoter region and exon 1 were deleted. The remaining deletions encompassed exons 2-10 (in two patients), exons 2-3, exons 4-5, or exon 8. When only patients who met the clinical criteria for PJS are considered, the overall mutation detection rate increases to 94% (64% point mutations and 30% large deletions). No mutation was identified in any of the 12 presumed cases. In conclusion, we found that approximately one-third of the patients who met the clinical PJS criteria exhibited large genomic deletions that were readily detectable by MLPA. Screening for point mutations and large deletions by direct sequencing or MLPA, respectively, increased the mutation detection rate in the STK11 gene up to 94%. There may be still other mutations in the STK11 gene that are not detectable by the methods applied here. Therefore, it is questionable whether a second PJS locus exists at all.

Video capsule endoscopy in peutz-jeghers syndrome: a blinded comparison with barium follow-through for detection of small-bowel polyps

BACKGROUND AND STUDY AIMS

Video capsule endoscopy has shown promise for the surveillance of significant small-bowel polyps in patients with Peutz-Jeghers syndrome. In this study the yield of significant small-bowel polyps by capsule endoscopy was compared to the yield of these polyps by barium follow-through in adults with Peutz-Jeghers syndrome.

PATIENTS AND METHODS

A total of 19 adults with Peutz-Jeghers syndrome who were undergoing surveillance underwent both capsule endoscopy and barium follow-through examinations, and the number of small-bowel polyps of at least 1 cm in diameter that were detected was recorded for each method. The two methods were assessed in terms of comfort and convenience for the patients and their preferred future surveillance method, using a questionnaire.

RESULTS

Capsule endoscopy detected a median of four significant small-bowel polyps while barium follow-through detected a median of one (P = 0.008). There was a trend towards more participants having at least one significant small-bowel polyp detected by capsule endoscopy than was the case with barium follow-through, though capsule endoscopy seemed to be less reliable for accurate sizing of polyps that were at the limit of clinical significance. Most participants expressed a preference for capsule endoscopy for future surveillance.

CONCLUSIONS

Capsule endoscopy should replace barium follow-through for the surveillance of small-bowel polyps in adults with Peutz-Jeghers syndrome, but the findings of this study should be interpreted with caution until a more reliable means of sizing polyps by capsule endoscopy is available.

[Clinical features and pathogenesis of Carney complex, a rare form of multiple endocrine neoplasia syndromes]

Carney-complex is the rarest and most recently described form of multiple endocrine neoplasia syndromes that is unique both from clinical and pathogenetic aspects. Clinical features include spotty skin pigmentation, cutaneous and cardiac myxomas, multiple endocrine abnormalities and schwannomas. The most characteristic endocrine abnormality is primary pigmented nodular adrenal hyperplasia that may result in clinically apparent Cushing's syndrome. Acromegaly, hyperprolactinaemia, tumours of the testis and ovaries have also been described. Approximately fifty percent of Carney-complex cases are familial, with an autosomal dominant inheritance pattern. About 45-65% of Carney-complex cases are related to mutations of the PRKAR1A gene encoding a regulatory subunit of protein kinase A, but other genetic mechanisms seem to be involved, as well. Here, the authors present a brief synopsis of its clinical and pathogenetical features.